What a Diagnosis of MS Looks Like

[Karen99]

I am posting my diagnostic summary as an example of diagnosing a case of multiple sclerosis.

Neurological examination:  This was a pleasant woman able to give a clear history.  A screening mental evaluation was unremarkable.  Cranial nerve examination revealed normal pupillary function.  Ocular excursions were full and visual fields were full to confrontation.  No spontaneous or gaze-evoked nystagmus was seen.  Facial strength and sensation were within normal limits.  Hearing was intact to finger rub bilaterally.  Palate and tongue function were normal.  Motor examination revealed normal muscle tone, strength, and bulk throughout.  Deep tendon reflexes were all hyperactive but without clonus, and symmetrical bilaterally.  Sensory examination revealed left body hypesthesia to light touch.  Coordination was excellent bilaterally with no evidence of any pastpointing.  Gait was normal and the patient was able to walk in tandem without difficulty.  Romberg sign was absent.  

Summary:
In brief, this 42-year-old woman has experienced multiple episodes of acute neurological dysfunction, including monocular visual loss and loss of color vision about a year ago, diplopia about two months ago, and left hemisensory disturbance for the past week or two.  Moreover, a recent brain MRI has revealed nonenhancing ovoid T2 hyperintensities.  She meets the diagnostic criteria for clinically definite relapsing remitting multiple sclerosis.  The MRI scan, WHILE NOT SPECIFIC, also has an appearance compatible with multiple sclerosis.  I do not think that any further neurological testing would be particularly helpful at this point.

Abbreviated History that are important for others to read.  Severe fatigue.  Painful visual loss (partial) (Optic Neuritis that was dx after the fact.  The docs do not have to witness ON or other symptoms repeatedly to obtain an accurate history)  Pain upon moving eyes.  Numbness over the left side of her body below the neck, burning numbness same area, left foot feels hot and at other times it feels numb to the touch.  Extensive workup (MS mimics).  Brain MRI reveal FOUR OR FIVE well circumscribed foci of round or ovoid T2 hyperintensity without enhancement.  The foci are primarily located in the PERIVENTRICULAR area of the left hemisphere white matter.  

I was diagnosed without an LP.  This came later at my request.  It was negative and DID NOT change my diagnosis.

My point of posting this is to demonstrate that neurologists do not have to witness every symptom firsthand repeatedly to recognize or document a "neurological episode."  There does not have to be a positive LP for diagnosis.  You do not have to be in a wheelchair to dx MS. You do not have to have a huge lesion load for diagnosis.  Lesions do not have to appear specific to MS to be MS. You do not have to add another lesion within 6 month to have MS.  (it took me another 3 years to see another lesion)  You do not have to add more symptoms within a specific timeframe to have MS.  

It is possible to have MS without the Babinski sign, L'Hermittes sign, clonus, an abnormal LP, an abnormal gait, or any other huge sensory or motor deficits to have MS.

This summary was written by a doctor at UCLA.  It was a 2nd opinion that I requested from my local neuro who diagnosed me initially.  He was not insulted when I asked for a 2nd opinion.  He actually encouraged me so I would accept the diagnosis.  Other than a few lesions, a history of comparatively mild neurological events, and hyper reflexes, everything else was normal.  

So it confuses me why others folks have a lot of lesions, more serious motor and sensory defects and are dismissed casually, often rudely, and often given a dx of a somatic illness.    Many are walking away with no explanation given for their debilitating symptoms and deficits than I had in 2001.  

I don't get it.  There is much credence to Quix's post titled Lies My Neuro Told Me
http://www.medhelp.org/posts/Multiple-Sclerosis/Lies-My-Neuro-Told-Me-or-Common-MS-Myths/show/1074879?personal_page_id=302&post_id=post_5046787  ;



  

[LATW]

The ON with lesions, that is what did it.  I can tell you from my experence and from my friends experence.

I had ON twice.  I was not diagnosed with my first episode even though I had what they thought was a lesion but on my second espisode of ON AND an MS specialist.  

I had a basically normal neuro exam at first as did my friend.  But not any more for both of us.  I have progressed a lot quicker than I had imagined I would.  

My friend has progressed and has more lesions.  

Anyway....ON and lesions on the MRI gets you a fairly quick dx. That is not the only thing of course but Karen99 did mention ON.

[MCBCON]

what an MS diagnosis looks like:

http://en.wikipedia.org/wiki/File:The_Scream.jpg

[StormyRenee]

I have been in limbo for almost a year now.This so frustrating for me because I am yet to get a definate MS dx. I have 15 brain lesions and all sorts of neurological weridness from head to toe.I was dx with TM already but now the neuro feels that I don't meet the criteria anymore  and may be heading towards MS. But yet I dont meet the MS criteria either. ????????

[mistylee]

Well my exam showed hyperreflexia with clonus both ankles , left leg a little ataxic, moderate differculty on the tandem gait. More than 8 lesions non specific in brain , none showing on the spine although the neuro requested thoracic specifically.  3 separate neuro attacks, over 3 years.
   Only a possible MS . ??? Hmmmm

Mistylee

[shawnie31]

Karen, thank you for this great informative post... It feels good to read something that gives me hope.. I would like my GP to read this and see what she thinks of it.

Thanks again!

Shelley
un-dx

[Udkas]

Thanks for sharing, very interesting.  I have hyper reflexia, clonus, can't tandem walk, over shoot the finger etc. etc. but i have a very normal MRI, not even a blemish to question but my neuro does give me a diagnosis, because of my neuro exam, his words are it is very strong evidence that I have a spinal lesion in my thoracic and because of my lhermettes he reckons in my cervical too.  

[Lulu54]

Karen,
Thanks for sharing - it sounds like you have few of the visible symptoms of MS, much like my own case.  I constantly wonder what it was that made my dx so simple when so many here struggle to get answers.

be well,
Lulu

[biowham]

I don't get it either. My neuro exam results, for example, are much more striking, including asymmetrical reflexes (hyper on right), upper motor neuron signs, deteriorated gait, jaw jerk, and right-sided weakness. I've got spots on my brain (about a dozen) and a myelopathy on my tspine. And I've got Lhermitte's. I present pretty clearly with a spinal syndrome. But my EPs and LP are normal. And here I sit! :-)

Bio

[jensequitur]

I don't get it either.  My neuro looked at my symptoms, looked at the tests, and said 'you have MS.'  How hard can it be?